Location: Fargo/Grand Forks, North Dakota

Year 1, Months 1-6

Interviews with Melissa Dau of FirstLink and Terri Lynn Graham of Altru Health System

What steps did you have to take to get your program off the ground?

FirstLink: As a result of being a grantee of Cohort 4 of the grant, FirstLink had a pre-existing relationship with Altru, but needed a more direct relationship with the Emergency Department Director and a Letter of Intent from the hospital CFO – there were a lot of legalities that needed to be worked out and approval needed to go through at the administrative level, regardless of approval from the ED and Psychiatry Director. On the crisis center side, the follow-up program changed and evolved for this new grant cycle based on research. FirstLink wanted to reach referred patients with 24 hours every time, instead of 24-48 hours, as was previous practice. In order to do that, if a referral comes in during a time when the lead follow-up clinician is not in, an on-call clinician will make the first contact as they have found that, even more than having the same person make all contacts, it’s most vital that the contact happen quickly after referral.

Altru: At the start of the process, Altru and FirstLink met face-to-face regarding the purpose of the grant and the best way to meet the objectives. Altru discovered that the best way to get buy-in on the hospital side was explain the “why” behind the project – sharing stories that “connected to the heart” helped to get people on board, and they were lucky enough to have a suicide survivor who is very active in the community who used to work in the ED as a physician who has been willing to share her experiences. The ED team was trained together on the process, and then also got the inpatient unit on board. Altru worked with their team on talking to patients about follow-up and using caring language, such as “I care about you as a person, and this is really important…”.

First Successes:

FirstLink: FirstLink has been very successful at expanding their follow-up program – in the Fall they did a webinar with all but two hospitals in the state and subsequently were able to sign MOUs with three more hospitals. When the hospitals sign an MOU, it gives the program an added point of contact so that it’s easy to touch base and be on the same page. More than anything, they are reaching people and making a difference, which really validates doing the work.

Altru: Getting buy-in from the ED staff has been a huge success! They have a smaller department, which has made educating and getting buy-in a little easier. Between the ED and the inpatient unit, they have been meeting their monthly goal for referrals. Another success has been adding a place to document the referral into the EHR, which acts as a visual cue to refer to the program.

First Challenges & Solutions:

FirstLink: Forms can be a challenge in terms of making sure the same information comes over regardless of the referring provider. In order to address this, they made a simple change and the hospital now puts patient information stickers on each form they send over, so that if there are questions or concerns about the information, connecting about the issue and resolving it has been simplified. FirstLink and Altru have been working hard to have weekly meetings and finding the time to do so can be difficult, so they have worked hard at making sure communication remains high quality through whatever method is possible that week, whether it’s phone calls or email to resolve pressing issues or communicate important project objectives. For the meetings, even if the ED Director can’t be there, someone else is.

Altru: As a result of previously being involved with FirstLink on follow-up, it was not difficult to execute the program, making it more difficult to identify that which has been a true challenge to the project. Inpatient psychiatry may have experienced some challenges in adopting the program, but as a result of doing a lot of discharge planning with patients, they have been able to surmount any challenges that they faced.

Emerging guidelines and best practices:

FirstLink: Implementing caring letters as part of their follow-up program has been foundational. After attending a webinar in January 2015, they started sending caring letters immediately after receiving the referral that include an encouraging quote, contact information for FirstLink, and a handwritten note. If appropriate, they will also send one during the ongoing follow-up process that is more personal. Participants have provided feedback that they really appreciated the caring letters.

Altru: To get people on board, help them connect to the “why” of the follow-up program and share stories with them that connect them to the heart of the project and how it’s making a difference. Educate your staff on how to make the referrals and expose them to patient testimony if possible as it helps to motivate them to continue to make the referrals. Altru has a promise to patients that they will include those people who are important to them in their care if the patient so desires, and at each staff meeting, they share compliments, complaints, and satisfaction scores, and this has helped when it comes to sharing feedback about the follow-up project.

What advice would you give to others who are looking to establish a follow-up program and partnership?

FirstLink: Go in person to the hospital and have direct contact with those people who you’re hoping to work with and need to get on board for the project. Find the people who work directly with the patients and can advocate for the need for follow-up and get those individuals on board first.

Altru: Tell stories and bring in people from the community who have been touched by suicide to help the team understand the difference that they will be making. In reality, follow-up referrals are extra work and EDs don’t have a lot of extra time – you HAVE to get buy-in from everyone and they need to understand how this piece of extra work is making a big difference.